Director Hepato-Neuro Lab @CRCHUM, Professor @Umontreal, President of @ishenliver; Neuroscientist; Passionate about hepatic encephalopathy; @LabHN
Joined October 2020
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Christopher F Rose retweeted
Check out the recently published article by @mapibafe @BloomPringle & @C_F_Rose
'The Pros & Cons of Measuring Plasma Ammonia
in the Management of Patients With Cirrhosis: An
ISHEN Debate'
onlinelibrary.wiley.com/doi/…
Christopher F Rose retweeted
1a) Welcome to an #accredited #tweetorial on #Hepatic_Encephalopathy (HE) in pts w/#cirrhosis: Part 1: epidemiology, classification, diagnosis & prognosis. Intended for practicing #PCPs and #GI specialists; supported by an independent educational grant from Bausch.
Christopher F Rose retweeted
39) That's part 1 — next: #pathophysiology. Follow us and don’t miss part 2 👉 #LiverTwitter
For now, claim your 0.75hr 🆓 CE/CME at academiccme.com/gastroent_CE…! Thanks to our expert authors @C_F_Rose and @RajivJalan1 !!
Christopher F Rose retweeted
38) Early diagnosis of HE is essential, and therefore HE should never be missed or neglected. However, preventing its occurrence and recurrence is even more important to preserve cognitive function, improve clinical outcomes, and reduce mortality.
Christopher F Rose retweeted
37) With ⬆️ing evidence that episodes of overt HE ➡️ permanent 🧠 injury & persistent neuro complications, pts w/history of episodes of overt HE ➡️indication or contraindication to LT merits revisiting. 🔓pmc.ncbi.nlm.nih.gov/article…
Christopher F Rose retweeted
36) Pts w/HE or history of HE who are transplanted face peri-operative conditions (intra-operative factors & insults) as well as exposed to post-LT #immunosuppression. Each step might ➡️irreversible components of brain injury & neuro complications.
🔓pubmed.ncbi.nlm.nih.gov/3030…
Christopher F Rose retweeted
35) The journey of 🧠 during the progression of liver disease is rough; the sensitive brain takes the brunt from being exposed to numerous factors & insults during liver disease ➡️encephalopathy, ⬇️ing brain reserve.
🔓pubmed.ncbi.nlm.nih.gov/3030…
Christopher F Rose retweeted
34) Recurrent overt HE may become refractory to treatment, ➡️progressive & persistent cognitive impairment that can remain even after liver #transplantation. Prevention of HE is the solution. See
pubmed.ncbi.nlm.nih.gov/3069…
🔓pubmed.ncbi.nlm.nih.gov/2125…
🔓pubmed.ncbi.nlm.nih.gov/2130…
Christopher F Rose retweeted
33) Persistent #hyperammonemia is associated with increased organ failure & mortality & may contribute to the development and progression of multiorgan failure & acute-on-chronic #liverfailure #ACLF.
See pubmed.ncbi.nlm.nih.gov/3070… and
pubmed.ncbi.nlm.nih.gov/3417…
Christopher F Rose retweeted
32) Where ammonia shines — PROGNOSIS: Outpatient ammonia >1.4× ULN predicts hospitalisation, complications & death, independent of MELD/Child-Pugh. See pubmed.ncbi.nlm.nih.gov/3587…
Christopher F Rose retweeted
31) #AMMON_OHE: ammonia + sex, diabetes, albumin, creatinine ➡️predicts an overt episode in outpatients, C-index 0.84, beating #PHES & #CFF. Ammonia as risk stratification, not diagnosis. Try it: 🔓 ammon-ohe.shinyapps.io/ammon…
See also pubmed.ncbi.nlm.nih.gov/3737…
Christopher F Rose retweeted
30) #Ammonia: The toxin at the centre of pathogenesis & the most misused test in hepatology. It does NOT dx HE, does NOT grade HE, & a ⬆️ level does NOT exclude a subdural. Don't order it to 'confirm' what you already decided.
pubmed.ncbi.nlm.nih.gov/2827… AND pubmed.ncbi.nlm.nih.gov/3309…
Christopher F Rose retweeted
29) Imaging is for exclusion, not for confirmation: T1 pallidal hyperintensity = manganese, present in most patients with cirrhosis, NOT evidence of HE. EEG slowing/triphasic waves: supportive, non-specific. See pubmed.ncbi.nlm.nih.gov/3309…
Christopher F Rose retweeted
28b) cont
🫢uremia
🫢non-convulsive status
🫢stroke
🫢benzodiazepines
👉 ~1/4 'encephalopathy' admits in cirrhosis have normal ammonia
Christopher F Rose retweeted
28a) Mimics that will embarrass you (per 🔓pubmed.ncbi.nlm.nih.gov/3572… & pubmed.ncbi.nlm.nih.gov/3987…:
🫢alcohol withdrawal
🫢Wernicke's
🫢hypoglycemia
🫢hyponatremia
🫢subdural
🫢sepsis
Christopher F Rose retweeted
27) The precipitant list you should recite in your sleep:
✅infection
☑️ GI bleed
✅constipation
☑️ AKI/dehydration
✅hypo-K
☑️ hypo-Na
✅diuretics
☑️ sedatives/opioids
✅Shunt #TIPS.
👉 TO DO: Culture EVERYTHING. Per 🔓pubmed.ncbi.nlm.nih.gov/3572… and pubmed.ncbi.nlm.nih.gov/3535…
Christopher F Rose retweeted
26) A NORMAL #ammonia in an untreated patient with altered mentation makes HE unlikely & should send you back to the mimics list. As stated in @EASLnews guidelines (2022) (LoE 4, strong, 95% consensus).
pubmed.ncbi.nlm.nih.gov/3572…
Christopher F Rose retweeted
25) Minimal HE: the iceberg: No symptoms, but falls, car crashes, unemployment, caregiver burden, poor QoL and 2–3X risk of progressing to overt HE. Screen everyone, per pubmed.ncbi.nlm.nih.gov/2155…& pubmed.ncbi.nlm.nih.gov/3309…
Christopher F Rose retweeted
24) Animal Naming Test: takes 1 min, free, language independent, <15 animals = abnormal. MMSE/MoCA are NOT fit for purpose: they miss the psychomotor slowing that defines #mHE.
See pubmed.ncbi.nlm.nih.gov/2827…
Christopher F Rose retweeted
23) Diagnosis of overt HE is clinical and one of EXCLUSION. No blood test confirms it. The pathway grade ➡️ precipitant ➡️mimics ➡️ ammonia (yes, in that order).
🔓pubmed.ncbi.nlm.nih.gov/3572…
